In previous blogs (here), I noted that interventions to help the person function better should facilitate a neuroplastic change of a dominant pattern towards “safety.” Activity pacing is one of the strategies I use to accomplish this.
Activity pacing is not the same as simply taking breaks or working until you can work no further. It is a learned skill that carries beliefs related to self worth, acceptance, empowerment, and independence. It is an important component of self management; and it promotes adaptive neuroplastic changes, and reduces disability.
Pacing is about doing, not avoiding. “I don’t do that because it hurts when I try” versus “I can clean my house for 30 minutes but then can do nothing else the rest of the day.” Both are strategies for self preservation that patients may implement. How I address them, differs between the two. Today I will focus on pacing.
First, understand the patient’s objective. Is it to reduce pain/prevent symptoms, to do more, achieve goals, or a combination of these.
Activity pacing can be used to achieve energy conservation, increased activity tolerance, and reduced disability. These are attained through planning, prioritizing, alternating tasks and gradually increasing activity. I help my patients review their activity and change their management strategy. This is accomplished by breaking tasks into smaller pieces, slowing down, activity/rest cycling, taking breaks, and switching tasks.
Pacing to reduce pain’s influence on function necessitates some level of acceptance on the part of the patient that the goal is to function better. This does not mean “no pain,’ but would mean better managed symptoms to tolerate activity. My experience with patients has been that being honest and telling them “our goal is to help you feel better so that you can do more” is met with appreciation that I’m not promoting unrealistic claims. Our first order of business is to help with strategies for self management to get back to what they love to do.
I commonly have patients tell me that they can perform X number of minutes of activity before they must take a break. But then they "pay for it later" in the form of being incapacitated for extended periods of time. This is not pacing. This is their maximum capacity. The point of pacing is to be able to do more, cumulatively, while minimizing flare ups. If an individual states that they have a 20 minute limit before they have to stop, I educate them to try taking a break at 15 minutes until they feel ready to continue. Then continue on for an additional 10-15 minutes, but not to the point of a flare up. Moving to the point of a flare up reinforces a maladaptive neuorplastic state. The "no pain, no gain" mindset can confound this for patients as they feel like the must do the most they can possibly do, even to a point of "system failure".
Working on pacing can help influence beliefs that flares ups are random and that an individual has no ability to impact their symptoms. These thoughts can diminish hope, internal locus of control, and agency. The value of perceiving that you are empowered to impact how you feel cannot be emphasized enough. I don’t give them an educational nugget to accomplish this. I help them to experience it.
Antcliff et al 2018 identified five categories that can be addressed for pacing: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance.
Activity consistency (doing the task daily) is associated with lower rates of depression, less avoidance, and increased physical function. In other words, higher self efficacy. I am not advocating performing a task amidst a flare up. I’m stating that there is pride and self worth and sense of accomplishment that can benefit the individual when they carry out a task, and do so regularly. This is something I work towards with patients. During our sessions, when performing tasks, sometimes the task may not change how they are feeling significantly. So I then pose the question: “if the task doesn’t make you feel worse, is there a benefit to you to DO the task?”
Prioritizing activities in this context may be useful too. Patients may benefit from guidance to help identify what is a priority instead of in what order things “usually” occur in. It may help people to opt to complete the bigger or more important task and “save up” smaller jobs for days they are feeling particularly well and feel they can add a task.
Some patients may already know what their time limitations are while others have less of a sense for it. These individuals may benefit from tracking their activity and symptoms for a few days.
How I document it:
Subjective: Patient notes that they are able to tolerate 20 minutes of housework including laundry before they must stop. After this, their symptom increase is so great that they must sit for 60+ minutes before being able to do anything else. Occasionally patient attempts longer durations but then they are unable to get out of bed for a full day after.
Objective: Pacing: Patient instructed to trial taking a break at 15'. Patient was educated that moving to the point of a flare up reinforces danger/pain messaging and their flared state. They re-verbalized understanding.
Assessment: Pacing may increase overall tolerance to perform more activity over the course of a day. Even though the patient understands that more activity can lead to a greater flare up, they also understand shortening the work time now may lead to greater activity over the course of the day.
Follow up session:
Subjective: The patient noted that over the last two days they would take a break after 15 minutes of activity, They were able to restart after a 40 minutes break (previously 60+ minutes). They were able to do this 3x over the morning 3 days out of the last week. Yesterday they attempted a 4th trial of activity but were unable to proceed due to symptom flare.
Objective: Pacing: Currently patient is tolerating 3x15minutes of activity with 40 minute breaks in between. They were educated to continue this for flare up prevention and management and increase time 10% every other week provided they do not experience significant symptom exacerbation..
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Antcliff, D., Keeley, P., Campbell, M., Woby, S., Keenan, A., & McGowan, L. (2018). Activity pacing: moving beyond taking breaks and slowing down. Quality Of Life Research, 27(7), 1933-1935.
Antcliff, D., Campbell, M., Woby, S., & Keeley, P. (2016). Activity Pacing is Associated with Better and Worse Symptoms for Patients with Long-term Conditions. The Clinical Journal of Pain,1. doi:10.1097/ajp.0000000000000401
Mccracken, L. M., & Samuel, V. M. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain,130(1), 119-125. doi:10.1016/j.pain.2006.11.016
Nielson, W. R., Jensen, M. P., Karsdorp, P. A., & Vlaeyen, J. W. (2013). A Content Analysis of Activity Pacing in Chronic Pain. The Clinical Journal of Pain,1. doi:10.1097/ajp.0000000000000024